Rhinoplasty Tutorial

(Note: All illustrations were created by Dr. Lam for his textbook, Comprehensive Facial Rejuvenation. All before and after photographs are also Dr. Lam’s patients.)

Anatomy

The nose is perhaps one of the most complicated anatomic features of the face. Obviously, this brief tutorial is not intended for the reader to be a master in nasal anatomy but to understand some of the fundamental anatomic considerations that impact on cosmetic and functional cosmetic nose enhancement

The nose is basically divided into three areas. The upper one third of the nose is made of nasal bones and is rigid and immobile. When there is a traumatic injury, the nasal bones are most likely broken and need to be realigned, as shown in the below Figure.

At times during major trauma, the middle third of the nose, which is made of semi-mobile cartilage, called the upper lateral cartilage, can also be damaged and must be repaired as in the following photograph.

This gentleman appears to have a bony hump but in fact has complete collapse of the middle third of his nose from a prior hockey accident which was meticulously rebuilt using septal cartilage from inside his nose. This is known as a saddle nose deformity.

The bottom third of the nose is made of very flexible cartilage, consisting of what is called the lower lateral cartilages, that make up the nasal tip. This example shows an individual who has lost almost his entire bottom third of his nose including part of his middle third of his nose, which had to be recreated in three layers: the inner mucosa, the cartilage framework (shown in the first illustration) and the outer skin.

As mentioned, the nose is essentially comprised of three layers, the inner mucosal layer, the cartilage and bony framework, and the overlying skin/muscle layer. The first illustration above focuses on the framework of the nose, which is the focus of cosmetic rhinoplasty. However, as shown in above figure, when all three layers are lost, the reconstruction must involve recreating each of the three layers with similar tissue.

Preoperative Evaluation
During a consultation, Dr. Lam is focused on all three layers of your nose to determine the candidacy for you to have a successful rhinoplasty. For a cosmetic result, the outer two layers, the skin and cartilage, are the most important layers for a meticulous evaluation. For functional rhinoplasty (to be discussed), the inner two layers are the most important, i.e., the framework and the inside of the nose.

The best analogy to understand how rhinoplasty works is to think of a tent. The outer fabric that hangs over the tent is analogous to the skin. The steel poles of the tent are considered the framework of the nose, i.e., the cartilage and nasal bones. Dr. Lam’s surgery involves working primarily on the framework of the nose (as mentioned, see Figure 1). Therefore, stronger steel poles of the tent (the cartilage and bone) permit a better, more defined aesthetic result. Thicker tent fabric that overlies the steel poles (that would be the skin) can limit what would be seen after cosmetic rhinoplasty. That is why Dr. Lam carefully evaluates your skin thickness and cartilage recoil during a consultation to decide 1) if you are candidate for rhinoplasty and 2) which method would be appropriate for you given your specific type of anatomy. For example, the thicker skinned Asian or African-American nose is usually (but not always) a candidate for traditional Occidental style rhinoplasty, and a different method must be used for a successful result.

Nasal and Facial Aesthetics

Over the years, there have been many aesthetic rules that have been devised to help guide plastic surgeons in determining what is considered beautiful and attractive. Although Dr. Lam has studied all of these rules, his emphasis during surgery is to perform rhinoplasty that is appealing to his artistic eye that will match your expectations established during consultation with him. Dr. Lam has included some basic rules on proportion and facial/nasal metrics herein for your education.

The nose should fit pleasantly on the face in terms of size and proportion both vertically and horizontally. A vertical rule of thirds suggests dividing the face into thirds from the bottom of the chin to the bottom of the nose, from the bottom of the nose to the top of the nose, and from the top of the nose to the beginning of the hairline. Obviously, this rule of thirds only serves as a basic guideline for understanding what would be ideal for a rhinoplasty patient. The rule of fifths is used to establish the ideal width of the nasal tip, which should be roughly equal to the width of the eye and the distance from the outer part of the eye to the outer part of the ear.

The ideal male nose and the ideal female nose are quite different. Dr. Lam is always careful to evaluate the nose in terms of overall facial shape but also in terms of the person’s gender. An ideal female nasal tip has a slight overall rotation upward but is much less upturned than compared with the ideal aesthetic from the 1980s for women. Today, the degree of rotation is more conservative. The nasal bridge height on a male can also be much higher and stronger than a female but in any case, the female nose should always maintain a straight not scooped profile.

The male nose below is shown with a reduction in the hump but maintenance of the overall strength and dimension that is required for masculinity.

The female nose below is more feminized by reducing a large profile hump and at the same tip rotating the tip upward a bit and refining the tip size to create a more feminine appearance.

The following illustrations provide basic rules that help establish what may be considered aesthetically pleasing in a Caucasian rhinoplasty. Unfortunately, there are no aesthetic rules that define non-Caucasian rhinoplasty and a discussion with Dr. Lam will help establish what shape and contour of your nose would best fit your aesthetic ideals in terms of preserving or softening your ethnic features.

As you can see in these two ethnic rhinoplasty examples, Dr. Lam has preserved the patient’s identity but created a more harmonious and aesthetically pleasing result. In the Vietnamese women, he gently raised the bridge without modifying the nasal tip and now the nasal tip appears to be smaller and more in proportion.

This African-American woman also exhibits a smaller bridge, which makes her tip look bigger. Dr. Lam reduced and refined her nasal tip at the same time as raising the nasal bridge. Now the bridge and tip are more harmoniously in balance and aesthetically pleasing.

Anderson’s Tripod: Nasal Tip Dynamics

The nasal tip is one of the most complicated anatomic areas to understand fully. The tip position and shape are the two important attributes when evaluating the nasal tip. Jack Anderson’s tripod metaphor for the nasal tip is the best

This woman underwent nasal tip refinement and slight rotation of the nose using a conservative trimming of her lower lateral cartilage and what is known as a dome-binding suture to elevate the nasal tip. The dome-binding suture works to create a narrower tip and also to rotate the tip upward. In narrowing the tip, the outer legs of the tripod are shortened and the middle leg is lengthened so the nasal tip rotates upward.

For a nose that is completely collapsed or markedly rotated downward like for the gentlemen pictured below, the outer legs of the tripod must be physically shortened using a technique known as a lateral crural overlay. This technique facilitated sufficient rotation of the tip upward to a more rejuvenated position and also permitted him to breathe much better.

This woman had an aggressive prior rhinoplasty which involved over-reduction of the nasal bridge, a twisted nasal tip, and over rotation and over projection (too long) of the nasal tip. She also could not breathe. Besides restoring her nasal passage by stenting the external valve (see below under Functional Considerations for more information), Dr. Lam performed a medial crural overlay in which the middle tripod leg was shortened in order to reduce the degree of rotation and projection of the nose. He also restored the height to the nasal bridge.

Functional Considerations

The nose is a respiratory organ, and the nasal airway must be preserved if not enhanced during rhinoplasty. Besides the septum (the partition that divides the nose), there are two other principal regulators of nasal airflow: the external nasal valve and the internal nasal valve. The external nasal valve essentially consists of the structures that make up the nostril of the nose.

External valve collapse can occur due to many causes. The gentleman pictured below has a condition known as rhinophyma. The exuberant overgrowth of his nose tissue has led to external valve collapse due to the weight of the tissue. Reduction of the overgrown tissue not only provided aesthetic improvement but also permitted him to breathe again.

At times, a nose that is over-reduced from prior rhinoplasty may have complete collapse. In this situation, alar-batten grafts can be used to strengthen, reinforce, and rebuild the integrity of the external valve like the flying buttresses in Romanesque architecture.

The internal nasal valve is the primary regulator of nasal airflow and can be compromised due to injury, prior rhinoplasty, or other causes. The internal valve is defined by the angle that the septum makes with the upper lateral cartilage.

In order to restore patency to the internal valve, the primary method is to open the angle with what is known as a spreader graft. The ideal spreader graft is derived from a graft borrowed from the septum.

This woman is shown after a prior accident with not only broken nasal bones but also a collapsed internal valve. The internal nasal valve was reconstructed on the right side using septal cartilage as a spreader graft along with other rhinoplasty refinements for aesthetic reasons.